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FROEDTERT MEMORIAL LUTHERAN HOSPITAL 9200 W WISCONSIN AVE MILWAUKEE, WI 53226 June 14, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, facility staff failed to perform resuscitative efforts per policy for one of six patient code events reviewed (Patient #1).

Findings:

Facility policy "Code 4 Team Responsibilities" dated 10/20/2015 states in part: "Policy...F. A Code 4 will be called for all cardiac/respiratory arrests...M. Code 4 will be called on all patients unless otherwise indicated in the EHR [Electronic Health Records] by the provider order...Procedure: A. Staff Member Discovering Arrest: 1. Establish unresponsiveness and note time. 2. Initiate Basic Life Support according to the American Heart Association standards and guidelines. 3. Following notification of the Code Team, assist with CPR, obtaining the code crash cart and notifying additional staff members that [code] has been called...6. Remain at the Code 4 site to give the Code 4 Team information about precipitating events of the Code 4, assessment at the time of discovery..."

Patient #1 was admitted to the facility on [DATE] for failure to thrive. The admission history and physical documents patient as a "full code." Admission orders on 5/22/2016 at 8:36 PM include "Full code; Continuous."

On 5/23/2016, the Respiratory Therapy note, timed 11:08 AM states: "Entered patient's room 1045 AM to complete respiratory care consult. Attempted to auscultate patient. No breath sounds heard or air movement from patient felt. Notified patient's nurse."

During an interview on 6/13/2016 at 1:50 PM, Director F described the following events: after finding Patient #1's nurse, RN A, both RN A and Respiratory Therapist E returned to Patient #1's room. RN A checked for breathing by placing a hand over the patient's nose and mouth area. After determining that Patient #1 was not breathing, RN A went to the nurse's station to page the MD and let the MD (Medical Doctor) know that the patient was deceased . At approximately 11:10 AM, 2 additional staff members (Nurse Educator G and RN H) were alerted to the situation, called a code and initiated CPR for Patient #1. Once resuscitative efforts had been initiated, RN A assisted in the code by performing compressions.

Review of Patient #1's code record on 5/23/2016 documents the event was recognized at 11:08 AM and CPR was initiated. Patient #1 received 1 shock and 1 dose of Epinephrine. Return of circulation is documented at 11:13 AM and the patient was intubated at 11:18 AM. The code ended at 11:23 AM and Patient #1 was transferred to the Intensive Care Unit (ICU).

Patient #1 remained in the ICU until the time of death at 4:02 PM on 5/28/2016. Patient #1's Death Summary states: "[Patient #1]...presented to the ED [Emergency Department]with complaint of generalized weakness, leg pain and should pain...Initially [Patient #1's] picture was attributed to failure to thrive by the admitting medicine team...[On 5/23/2016] At 10:45, a respiratory therapist came in...and found that the patient was unresponsive. Eventually a code was called...In the unit [#1] was noted to be hypotensive and to lack brainstem reflexes...by the fourth day of unresponsiveness we recommended withdrawal of care, anticipating that the best neurologic outcome would be persistent vegetative state. ...On 5/28 at 3:00 PM, family arrived and requested terminal extubation..." Review of the same report further revealed: "Complications in the hospital: Cardiopulmonary arrest, likely secondary to [DIAGNOSES REDACTED] septic shock."

During an interview on 6/13/2016 at 3:10 PM, Respiratory Therapist E stated that upon arrival to Patient #1's room, Patient #1 was lying in bed, "not normal" and the patient "didn't respond." "I auscultated both sides [of the chest] and there were no breath sounds." When asked why E didn't initiate a code, E stated "I went to get the nurse first."

Per facility investigation records dated 5/23/2016 and 5/25/2016, in an undated, written statement, RN A wrote: "I placed my hand in front of the patient's nose and mouth, no breath felt, no chest rise noted. RT said that the patient felt cold, and stiff, left room, and went back to the nurse's station to page physician, and announced in the nurse's station that the patient was found deceased ...A short time later, the nurse educator, and the discharge coordinator entered the patient's room. Stated that [Patient #1] was still warm, and that we should code the patient due to policy."

During interviews on 6/13/2016, staff were questioned about facility expectations and what to do if a staff member discovered a patient who was not breathing. At 10:50 AM, RN I stated "anyone" can call a code. RN H stated at 10:55 AM, all patients who are not a full code have wear a bracelet to identify their status. RN H stated "anybody and everybody" can call a code, and all CPR certified staff members are qualified to initiate resuscitative efforts. During an interview at 1:50 PM, Director F stated "if [staff] are trained in CPR, I would expect them to call a code and start [CPR]." Respiratory Therapy Manager J stated during an interview at 2:50 PM, "RTs [Respiratory Therapists] are trained in CPR and are capable of initiating CPR and calling a code...they do call codes when needed." Manager J went on to state "[RT E] touched and [Patient #1] felt cold...[RT E] presumed the patient was dead...I'm confident that [RT E] had acted appropriately."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the facility failed to ensure that staff initiated cardiopulmonary resuscitation per facility policy for one of six patients who were found without a pulse or respirations (Patient #1).

Findings:

See tag A144.